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APPLICATION FOR WELUPUMP PERMIT <br />JOAQUIN COUNTY PUBLIC HEALTH SERVICES U0 4.10 y S <br />ENVIRONMENTAL HEALTH DIVISION <br />P 0 SOX 388, 445 N. SAN JOAQUIN ST., STOCXTON, CA 96201.388 PAYMENT <br />(209) 468.3420 <br />DECEIVED <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />(Comploto in lkwouI <br />Application is here by made to the San Joaquin Canty for a permit to construct and/or install the !!��,,� N44B4I<i'bed. This application is <br />made in compliance with San Joaquin County Develcpment Title, Chapter 9-1115.3 and the Standards Pq� Wa IQlquin County Public Health <br />services, Environmental Health Division. r ENVIUURONME`�1"L' <br />ob Address/or APN# 4' 18, �uSZ / ✓����1y t . City O Ly Parcel Size/APN# 2 <br />Ho <br />Owner's Name ���fru titer �iv G . Address Sa !� r'rd sr. ,9 93,Z-?& Phone <br />Contractor lgclr / . JUr PN /UI�Address ­ 01,1 r,,df, HVIS,,�� Lic# Phone #c��� <br />t9. oXLic# <br />or / ��Phone # ! ��-8SZ'yY��r <br />Sub Contractor/"{� Y�cl?ol� C/r,,'NC Address /lam. t) r-6 O CorcatJG CI`! <<5 7• ��07� <br />TYPE OF WELL/PUMP: <br />[] <br />NEW WELL <br />[] RE?LACEMENT WELL [] MONITORING WELL # Tom' <br />Cl OTHER <br />PE CODES <br />FEEINNFO <br />❑ <br />DESTRUCTION <br />[J OUT -OF -SERVICE WELL [] GEOPHYSICAL WELL <br />SOIL BORING <br />[I <br />INSTALLATION <br />[] WELL SYSTEM REPAIR [] CROSS -CONNECT REPAIR <br />Ijj' VAPOR EXTRACTION WELL <br />[(� , <br />[I <br />New ❑ Repair <br />H.P. DEPTH PUMP SET <br />FT. <br />FIRST WATER LEVEL <br />1J <br />(TYPE OF PUMP) <br />qk� <br />INTENDED USE <br />TYPE OF WELL <br />CONSTRUCTION SPECIFICATIONS <br />[] INDUSTRIAL <br />[] <br />OPEN BOTTOM <br />DIA. OF WELL EXCAVATION 8 <br />DIA. OF <br />CONDUCTOR CASING <br />DOMESTIC/PRIVATE <br />[] <br />GRAVEL PACK/SIZE <br />TYPE OF CASING/STEEL/PVC /�[/ C <br />DIA. OF <br />WELL CASING <br />[] PUBLIC/MUNICIPAL <br />[] <br />DRIVEN <br />DEPTH OF GROUT SEAL )L, CJ � <br />SPECIFICATION; <br />Cl IRRIGATION/AG <br />[I <br />OTHER <br />GROUT SEAL INSTALLED BY -01/81 ✓ <br />GROUT BRAND <br />NAME <br />r] MONITORING <br />GROUT SEAL PUMPED: 1 Yes U No <br />CONCRETE <br />PEDESTAL BY DRILLER: [I Yes , ,Nc <br />APPROX. DEPTH <br />LOCKING CHESTER BOX/STOVE PIPE <br />PROPOSED CONSTRUCTIONIDRILLING <br />METHOD: MUD <br />ROTARY_ AIR ROTARY_ AUGER,_ CABLE_ OTHER_ <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, <br />State Laws, and Rules and Regulations of the San Joaquin County. Home owner or Licensed agent's signature certifies the fol Lowing: "'. <br />certify that in the performance of the work for which this permit is issued, I shall not employ persons subject to WORKMAN'S COMPENSATION <br />Laws of California." Contractor's hiring or s;b-contracting signature certifies the following: " I certify that in the performance <br />or tre work for which this permit is issued, I s`.alL employ persons subject to WORKMAN'S COMPENSATION Laws of California." THE APPLICANT <br />MUST CALL 24 HH/URS IN ADVANCE FOR ALLEQUIRED INSPECTIONS AT (209) 488.3423. Complete drawing at Lower area provided./ i <br />signed X� r!�/[if iiti �'� Title6-,ui //•L7e-,, DateJ�i�' �M <br />DEPARTMENT USE ONLY / 9 <br />Application Accepted By Date Area <br />Grout Inspection By <br />Destruction Inspection By <br />&rrnllYTlNr. nNIY• I AID# <br />_ Date Pump Inspection By <br />Date Garments :.le/ <br />FAC# <br />Date <br />CHECXfgCASH RECEIV O BY DATE <br />PERMITISERVICE REQUEST NUMBER INVOICE <br />PE CODES <br />FEEINNFO <br />AMOUNT REMITTED <br />[(� , <br />